Provider Demographics
NPI:1184015448
Name:KANESA-THASAN, RITI MAHADEVIA
Entity Type:Individual
Prefix:
First Name:RITI
Middle Name:MAHADEVIA
Last Name:KANESA-THASAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RITI
Other - Middle Name:JAGRUT
Other - Last Name:MAHADEVIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:132 S 10TH ST
Mailing Address - Street 2:SUITE 780-A MAIN BLDG
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5244
Mailing Address - Country:US
Mailing Address - Phone:215-503-4529
Mailing Address - Fax:
Practice Address - Street 1:132 S 10TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5244
Practice Address - Country:US
Practice Address - Phone:215-955-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT2103022085R0202X
PAMD4696832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology